2. INTRODUCTION
• The process of case selection and treatment planning begins after a
clinician has diagnosed an endodontic problem.
• Proper selection of cases avoid pitfalls during endodontic treatment
and helps to ensure success.
• Errors in the case selection, some of which could have been
avoided, constituted 22% of failures reported in a study conducted
by Ingle and Beveridge.
• The use of rotary instruments, ultrasonics, and microscopy as well
as new materials has made it possible to predictably retain teeth that
previously could not have been treated. But in spite of all these
development case selection is the 1st step towards saving a tooth.
3. CONSIDERATIONS PRIOR TO
ENDODONTIC THERAPY
1.Is the tooth needed or important? Could it some day
serve as an abutment for prosthesis?
2.Is the tooth salvageable, or is it so badly destroyed that it
cannot be restored?
3.Is the entire dentition so completely broken down that it
would be virtually impossible to restore?
4. 4. Is the tooth serving esthetically, or would the patient be
better served by its extraction and a more cosmetic
replacement?
5. Is the tooth so severely involved periodontally that it
would be lost soon for this reason?
6.Is the practitioner capable of performing the needed
endodontic procedures?
5. FACTORS OF CASE SELECTION
• Case selection is broadly based upon three factors
• Factors associated with teeth.
• Factors associated with patients health.
• Factors associated with clinician.
6. FACTORS ASSOCIATED WITH TEETH
1st step always should be examination of the teeth and oral
cavity . Clinician should judge whether the teeth needed any kind
of endodontic treatment or not.
• Indication
1.Teeth with pulpal inflammation
pulpal inflammation like irreversible pulpitis , chronic
hyperplastic pulpitis, pulpal necrosis require endodontic
treatment.
7. 2. Teeth with periapical pathosis.
Periapical pathology or diseases of periradicular tissue, like
acute or chronic apical periodontitis, acute or chronic periapical
abscess can be treated by endodontic procedure.
8. 3. Fractured teeth
Fractured teeth often require endodontic treatment which helps to
maintain its normal esthetic form and functional properties.
Deciduous teeth having pulpal involvement and crown fracture
required treatment procedure like pulpotomy, direct pulp capping,
apexification, apexogenesis.
Vertical crown fracture in multi rooted teeth involving furcation can
also be treated by endodontic procedures like hemisection followed
by root canal therapy.
9. 4. Facilitation of restoration (Intentional Endodontic Treatment).
Occasionally, intentional endodontic treatment of teeth with
perfectly vital pulps may be necessary. Examples of situations
requiring intentional endodontic treatments include hyper
erupted teeth or drifted teeth that must be reduced so
drastically that the pulp is certain to be involved.
On other occasions, a pulp is intentionally removed and the
canal filled so that a post and core may be placed for
increased crown retention.
10. CONTRAINDICATING FACTORS OR FACTORS
WHERE SPEACIAL ATTENTION IS NEEDED-
1. Insufficient periodontal support- In Teeth having grade three
mobility extraction is preffered over endodontic treatment
A tooth with a poor periodontal prognosis may have to be sacrificed,
despite a favorable endodontic prognosis.
11. The radiographic appearance of combined endodontic–periodontal
lesions may be similar to that of a vertically fractured tooth.
• Therapy for true combined lesions requires both endodontic and
periodonal therapy
• those lesions that develop as a result of both pulpal
infection and periodontal disease—respond to a
combined treatment approach in which endodontic
intervention precedes, or is done simultaneously
with, periodontal treatment.
12. 2. Improper positioning of teeth-
Partially erupted, impacted and malpositioned teeth are
contraindicated for endodontic treatment.
It is very difficult to make proper accessibility and
isolation while doing endodontic treatment in these
malposed teeth.
13. 3. Non restorable teeth-
The restorability of a tooth requiring endodontic treatment
depends on the amount of sound tooth structure remaining.
Teeth with very less amount of crown and extremely carious
are contraindicated for endodontic treatment.
Teeth which are grossly
decayed (both crown and
root)also contraindicated for
endodontic treatment
14. 4. Abnormal canal configuration-
Severely curved canal, c shaped canal, aberrant extra canals are
very difficult for instrumentation
Teeth with such canal configuration are not ideal for endodontic
treatment.
Curvature of 20º in a
narrow root canal is very
difficult to negotiate also
a curvature of 30ºwith a wide canal
is not easily negotiable.
The degree of curvature ,size and
constriction of the root canal must
be judged prior to endodontic
treatment
16. 6. calcification of canal-
Excessive calcification of canal prevents proper instrumentation .
Which may cause failure of endodontic treatment or iatrogenic errors
like perforation, ledging etc.
Such cases should be selected judiciously.
17. 7. Crown root ratio -
An unfavorable crown/root ratio that exceeds 1:1 is more
susceptible to eccentric occlusal forces, and hence
prognosis is poor.
Sometimes these teeth maybe indicated for extraction,
but before a decision for extraction is made referral to a
prosthetic dentist for an accurate evaluation maybe
necessary.
18. 8. Iatrogenic error.
Painfull T
eeth where previous attempt of endodontic
treatment has been done often show ledges,
perforations, broken instruments in the canals.
Prognosis of such cases are questionable if not treated
properly.
19. FACTORS ASSOCIATED WITH PATIENT’S
HEALTH
• Before starting endodontic treatment the clinician must take
proper medical history about the patient, The clinician should
search for following informations -
History of allergies
History of drug interactions, adverse effects
Anxiety (past experiences and management strategy)
Presence of prosthetic valves, joints, stents,
pacemakers
Required Antibiotics (prophylactic or therapeutic)
20. Hemostasis (normal expected, modification to treatment)
Infiltration or block anesthesia with or without vasoconstrictor
Significant equipment concerns (radiographs, ultrasonics,
electrosurgery)
Emergencies (potential for occurrence, preparedness)
21. American Society of Anesthesiologists Physical
Status Classification System-After obtaining the above
informations the clinician should access the physical status of the patient.
P1: Normal, healthy patient; no dental management
alterations required
P2: Patient with mild systemic disease that does not interfere
with daily activity or who has a significant health risk factor
(e.g., smoking, alcohol abuse, gross obesity)
P3: Patient with moderate to severe systemic disease that is
not incapacitating but may alter daily activity
P4: Patient with severe systemic disease that is incapacitating
and a constant threat to life
22. Common Medical Findings That may Influence
endodontic treatment planning
1. Cardio vascular disorder-
the history of patients with cardio vascular disorder should be
taken cautiously.
Patients with some forms of cardiovascular disease are
vulnerable to physical or emotional stress that may be
encountered during dental treatment, including endodontics.
Consultation with the patient’s physician is mandatory before
the initiation of endodontic treatment.
Treatment should be delayed in case of-
1. Myocardial infraction within 6 months.
2.Coronary bypass graft surgery less than 3 months.
3.H/o stroke less than 6 months.
23. oAntibiotic prophylaxis-
Antibiotic prophylaxis is needed to prevent bacterial
endocarditis which can be caused by endodontic surgeries.
PROCEDURES NOT NEEDING ANTIBIOTIC
PROPHYLAXIS-
• Restorative dentistry with or without gingival retraction cord
• Local anesthesia (non-PDL)
• Root canal therapy (not beyond apex)
• Impressions
• Suture removal
• Placement of the rubber dam
24. NEW GUIDELINES:AHA CONSIDERS HIGH
RISK INDIVIDUALS-PREMEDICATION
INDICATED
• Prosthetic cardiac valve: mechanical or tissue
• Previous history of infective endocarditis
• Congenital Heart Disease which is unrepaired
• Congenital heart defects repaired during the first six
months of endodontic surgery
• Cardiac Transplant with cardiac complications
25. CONSIDERED MODERATE RISK INDIVIDUALS-
PREMEDICATION NOT INDICATED NOW
• Mitral Valve Prolapse with or without regurgitation
• Pathological/Organic heart murmur
• Previous rheumatic fever with or without valvular dysfunction
• Previous Kawaskasi disease with or without valvular
dysfunction
• Systemic Lupus Erythematosus (1/4 of these patients have
cardiac involvement)
• Rheumatoid Arthritis with cardiac involvement
• Other acquired valvular dysfunction
26. CONSIDERED MODERATE RISK INDIVIDUALS-
PREMEDICATION NOT INDICATED NOW
(CONT.)
• Previous coronary bypass graft surgery
• Coronary artery stents
• Heart transplants patient without complications
• Cardiac pacemakers
• Implanted defibrillators
27. ANTIBIOTIC PROPHYLAXIS REGIMEN
⚫ Following current loading guidelines:
► 30-60 minutes before procedure
► Next 1 to 2 hours is the best coverage
of antibiotics
► Ideally give subsequent loads of
antibiotics 9 to 14 days after initial treatment to allow the
oral flora to return to normal
⚫ The dose can be given 2 hours after the procedure if it was
accidentally not given
28. PATIENTS ALREADY RECEIVING
ANTIBIOTICS
• Select an antibiotic from a different class rather than
increase dosage of current antibiotic to minimize
resistance
Example: If patient is already taking
amoxicillin, use clindamycin.
29. AMERICAN HEART ASSOCIATION
RECCOMENDATION- NEW GUIDELINES
• Adults
Amoxicillin 2 grams orally (500 X 4 tablets), 30-60
minutes before appointment
• Children
Amoxicillin 50mg/kg. orally, 30-60 minutes before
appointment
30. Situation Antibiotic Agent Regimen *
Standard Prophylaxis Amoxicillin Adults: 2.0 g.
Children : 50 mg / kg
Orally 30-60 minutes before procedure
Unable to take oral
medication
Ampicillin Adults: 2.0 g IM or IV
Children: 50 mg / kg IM or IV
within 30-60 minutes before procedure
Allergic to Penicillin Clindamycin Adults: 600 mg
Children: 20 mg / kg
Orally 30-60 minutes before procedure
** Cephalexin or cefadroxil Adults: 2.0 g
Children: 50 mg / kg
Orally 30-60 minutes before procedure
Azithromycin or
clarithromycin
Adults: 500 mg
Children: 15 mg / kg
orally 30-60 minutes before procedure
Allergic to Penicillin and
unable to take Oral
Medications
Clindamycin Adults: 600 mg
Children: 20 mg / kg IV 30-60 minutes
before procedure
Cefazolin Adults: 1.0 g
Children: 25 mg / kg IM or IV
within 30-60 minutes before procedure
* Total children’s dose should not exceed adult dose
** Cephalosporin's should not be used in individuals with immediate-type hypersensitivity reaction to penicillins
31. oAnti coagulant therapy-
There is a widespread belief among dental clinicians
and physicians that oral anticoagulant therapy in which
patients receive drugs such as warfarin (Coumadin)
must be discontinued before dental treatment to prevent
serious hemorrhagic complications.
It should be noted that the anti coagulant therapy is only
a matter of concern if there is a need of endodontic
surgery.
Minor endodontic procedures , even root canal
treatment does not need any modification in anti
coagulant therapy.
32. Before endodontic surgery the INR value should be
checked the permissible limit of INR of the patient taking
anticoagulant drug is 2.5-3.5.
If the value is more than 3.5 dentist should consult
physician before any surgical procedure.
Patients taking digitalis or patients with unstable angina
should be treated cautiously as in these cases
vasoconstrictor precipitate arrythmia.
33. 2. Pregnancy
Any type of endodontic treatment should be done only in
2nd trimester.
While in chair patient should be placed in left lateral
position.
Drug having teratogenic effect and may cross placental
barrier should be avoided.
34. 3. Diabetes mellitus
Patients with diabetes, even those who are well controlled,
require special consideration during endodontic treatment.
Studies suggest that diabetes is associated with a decrease in
the success of endodontic treatment in cases with retreatment
periradicular lesions.
There is also evidence of poor prognosis after endodontic
treatment due to more prevalence of periodontal disease.
Patients should be given short morning appointment to avoid
peak insulin action which may cause hyperglycemic shock.
Before any endodontic surgery blood sugar must be checked.
Surgery is not permissible in poorly controlled and in
uncontrolled cases.
35. 4. Hiv
when treating patients with acquired immunodeficiency
syndrome (AIDS), that the clinician understand the
patient’s level of immunosuppression, drug therapies, and
potentiality for opportunistic infections.
Although the effect of human immunodeficiency virus
(HIV) infection on long-term prognosis of endodontic
therapy is unknown, it has been demonstrated that
clinicians may not have to alter their short-term
expectations for periapical healing in patients infected with
HIV.
36. vital aspect of treatment planning for the patient with
HIV/AIDS is to determine the current CD4+ lymphocyte
count and level of immunosuppression. In general, patients
having a CD4+ cell count exceeding 400 mm3 may receive
all indicated dental treatment.
Patients with a CD4+ cell count less than 200 mm3 will have
increased susceptibility to opportunistic infections and
may be effectively medicated with prophylactic drugs.
Clinician should always use disposable instruments and
should be cautious about any type of contamination.
37. 5. End-Stage Renal Disease and Dialysis
Consultation with the patient’s physician is suggested
before any dental procedure is initiated for patients being
treated for end-stage renal disease. Depending on the
patient’s status and the presence of other diseases
common to renal failure (e.g., diabetes mellitus,
hypertension, and systemic lupus erythematosus).
The most recent American Heart Association guidelines
do not include a recommendation for prophylactic
antibiotics before invasive dental procedures for patients
receiving dialysis with intravascular access devices.
38. Some drugs frequently used during endodontic
treatment are affected by dialysis. Drugs metabolized by
the kidneys and nephrotoxic drugs should be avoided.
Endodontic treatment is best scheduled on the day after
dialysis, because on the day of dialysis patients are
generally fatigued and could have a bleeding tendency.
39. 6. Reduced mouth opening-
Patients with OSMF, ankylosis, Trismus are difficult to
treat with endodontic treatment because of their reduced
mouth openning.
7. Age of the patient-
Age of the patients should be a matter of concern for the
endodontist.
Treatment is very difficult for geriatric patients. May be
single visit .
40. 8. Epilepsy-
Once a patient with epilepsy has been identified, the
dental practitioner must learn as much as possible about
the seizure history, including the type of seizures, age at
onset, cause (if known), current and regular use of
medications, frequency of physician visits, degree of
seizure control, frequency of seizures, date of last
seizure, and any known precipitating factors.
41. Patients not taking medication or having history of
epileptic attack within last 3 months should not be
treated.
Fortunately, most epileptic patients are able to attain
good control of their seizures with anticonvulsant drugs
and are therefore able to receive normal routine dental
care.
42. erythromycin should not be administered to patients who
are taking carbamazepine because of interference with
metabolism of carbamazepine, which could lead to toxic
levels of the anticonvulsant drug.
Aspirin and nonsteroidal anti-inflammatory drugs
(NSAIDs) should not be administered to patients who are
taking valproic acid because they can further decrease
platelet aggregation, leading to hemorrhagic episodes.
43. 9. Bisphosphonate Therapy-
Bisphosphonates offer great benefits to patients at risk of
bone metastases and in the prevention and treatment of
osteoporosis.
A patient’s risk of developing osteonecrosis of the jaw
while receiving oral bisphosphonates appears to be low,
but there are factors known to increase the risk for
bisphosphonate-associated osteonecrosis (BON).
44. • For patients at higher risk of BON, surgical procedures
such as extractions, endodontic surgery, or placement of
dental implants should be avoided, if possible. Sound
oral hygiene and regular dental care may be the best
approach for lowering the risk of BON.
45. 9. Malignancy-
When a clinician begins an endodontic procedure on a
tooth with a well-defined apical radiolucency, it might be
assumed to result from a nonvital pulp.
Pulp testing is essential to confirm a lack of pulp vitality
in such cases. A vital response in such cases is
indicative of a nonodontogenic lesion.
46. Some malignancies may metastasize to the jaws and
mimic endodontic pathosis, whereas others can be
primary lesions . A panoramic radiograph is useful in
providing an overall view of all dental structures.
Careful examination of pretreatment radiographs from
different angulations is important because lesions of
endodontic origin would not be expected to be shifted
away from the radiographic apex in the various images.
47. • Patients undergoing chemotherapy or radiation to the
head and neck may have impaired healing responses.
Treatment should be initiated only after the patient’s
physician has been consulted.
• It is advised that symptomatic nonvital teeth be
endodontically treated at least 1 week before initiating
radiation or chemotherapy, whereas treatment of
asymptomatic nonvital teeth may be delayed.
48. 10. Asthma & other respiratory tract disorder-
Clinician should ask for respiratory disorders like
asthma, COPD or chronic bronchitis.
Endodontist should access the present physical
condition of the patient on the basis of signs, symptoms
and treatment history.
Moderate and severe cases of asthmatic patients
should not be treated by endodontist with out
consultation of physician.
49. Avoid treatment if upper respiratory tract infection is
present, and treatment should always be done at upright
position.
Avoid precipitating factors, rubber dam, gingival
retraction cord, L.A with vasoconstrictors.
Patient should bring inhaler .
Appointment should be short.
50. Drugs like NSAIDS, narcotic drugs, anti cholinergic
drugs, anti histamines should be avoided.
There is also chances of drug interaction between
asthmatic drugs and antibiotics.
Chronic corticosteroid users may require steroid
supplementation
51. 11. Bleeding disorders-
Endodontic treatment is generally low risk for patients
with bleeding disorders. If a pulpectomy is indicated, the
possibility of the tooth requiring conventional endodontic
treatment must also be considered.
It is important that the procedure be carried out
carefully with the working length of the root canal
calculated to ensure that the instruments do not pass
through the apex of the root canal.
52. The presence of bleeding in the canal is indicative of pulp
tissue remaining in the canal. Sodium hypochlorite should be
used for irrigation in all cases, followed by the use of calcium
hydroxide paste to control the bleeding.
require a written consent from the physician Specially when
prescribing analgesics and antibiotics.
• In Hemophilia patients there may be bleeding with
injection , pulp extirpation and rubber dam application.
However RCT is more safe than extraction after consulting
physician.
53. Formaldehyde-derived substances may also be used in
cases where there is persistent bleeding or even before
the pulpectomy.
Dental pain can usually be controlled with a minor
analgesic such as paracetamol (acetaminophen). Aspirin
should not be used due to its inhibitory affect on platelet
aggregation.
The use of any non-steroidal antiinflammatory drug
(NSAID) must be discussed beforehand with the
patient's hematologist because of their effect on platelet
aggregation.
For anesthesia patient should only be given buccal
infiltration.
54. FACTORS ASSOCIATED WITH CLINICIAN
The clinician should have proper endodontic instruments and
clinical set up for the treatment.
The clinician should have well equipped hands for treatment.
